Wiki Not sure if this is fraudulent billing or where to find documentation stating it is

[TonyaWasson]

Is it illegal for a non medical transportation provider to bill medicaid for services that they were reimbursed for under a grant program from a mental health facility? I know this is a moral question and easy to respond with our moralistic believes, I am needing to find something in writing that states that it is not legal or is fraudulent or if there is nothing written I just need to know that it is not written anywhere. Thank you for you responses.

 

[SharonCollachi]

I cannot think of a single situation where Medicaid is NOT the payer of last resort, except in the case of Victims of Crime Programs (aka, Victim Witness Programs), where VCP would pick up a client share of cost. If they were paid for services under ANY program, they cannot bill Medicaid for those same services as if they were not already paid.

Here is the Medicaid policy on billing Medicaid for services provided free of charge, which sounds like it does not apply, but hang with me for a moment: https://www.medicaid.gov/federal-po...ervices-provided-without-charge-free-care.pdf

And within that document is this statement, which can be broadly applied and is applicable to this scenario:

As is the case more generally, FFP for Medicaid payments is available only when all of the following elements are satisfied:
•The individual is a Medicaid beneficiary.
•The service is a covered Medicaid service, provided in accordance with the approved state plan methodologies, including coverage under the Early and Periodic Screening Diagnostic and Treatment (EPSDT) benefit provided to children.
•The provider is a Medicaid-participating provider and meets all federal and/or state provider qualification requirements.
•The state plan contains a payment methodology for determining rates that are consistent with efficiency, economy and quality of care.
•Third party liability (TPL) requirements are met.
•Medicaid payment does not duplicate other specific payments for the same service.
•The state and provider maintain auditable documentation to support claims for FFP.
•The state conducts appropriate financial oversight of provider billing practices.
•All other program requirements (statutory, regulatory, policy) for the service, payment, and associated claiming are met.



See that underlined statement? There's your answer.

 

[thomas7331]

I think this would be more of a legal and accounting question than coding/billing, but either way, you'd need to know more about the agreements in place and state Medicaid rules for reimbursement in this situation.

My thoughts are that if the grant only paid a portion of the cost, then the provider might be eligible for additional funds from Medicaid. If, however, the agreement under the grant was to be payment in full, then any additional payment from Medicaid would create a credit balance on the account, unless the contractual agreements were not properly posted. Under most state laws, it's illegal to retain credit balances as the funds are required to be returned to their rightful owner or, if that's not possible, to be relinquished to the state as unclaimed property.